Lies, Edzard Ernst, and Research: Don't Believe Everything You Read

There have been several articles published in medical research journals which are pointing out just how flawed, biased, and just plain wrong biomedical research has become. Such studies can cause serious harm. Paxil was used as a teen anti-depressant  for years, largely based on a study which massaged the data to come to absolutely false conclusions about its safety and efficacy. Vioxx, the miracle painkiller that killed, was allowed on the market due to research designed to hide its deadly side effects.  As far back as 2003, bias was noted in the biomedical reesarch literature, but little has been done to change things. At most, some journals ask investigators to self-report any conflicts of interest they may have. Of course, few do.

The fact of the matter is, that pharmaceutical companies control the vast majority of grant money going to research institutions, and as an investigator, your livelihood can be put on the line if your grant money dries up.

Not surprisingly, bias and hidden agendas come up in the research on alternative medicine and chiropractic in particular. Mostly this occurs in the form of journal articles using research that has been hand-crafted to make chiropractic spinal manipulation appear dangerous -- when, in fact, you have a higher risk of serious injury while driving to your chiropractor's office than you do of any treatment you receive while you're there.

A case in point is the article, "Adverse effects of spinal manipulation: a systematic review," authored by Edzard Ernst, and published in the Journal of the Royal Society of Medicine in 2007. Ernst concludes that, based on his review, "in the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation."

This conclusion throws up several red flags, beginning with the fact that it flies in the face of most of the already-published, extensive research which shows that chiropractic care is one of the safest interventions, and in fact, is  safer than medical alternatives.

For example, an examination of injuries resulting from neck adjustments over a 10-year period found that they rarely, if ever, cause strokes, and lumbar adjustments by chiropractors have been deemed by one of the largest studies ever performed to be safer and more effective than medical treatment.

So the sudden appearance of this study claiming that chiropractic care should be stopped altogether seems a bit odd.

As it turns out, the data is odd as well.

In 2012, a researcher at Macquarie University in Australia, set out to replicate Ernst's study. What he found was shocking.

This subsequent study stated that "a review of the original case reports and case series papers described by Ernst found numerous errors or inconsistencies," including changing the sex and age of patients, misrepresenting patients' response to adverse events, and claiming that interventions were performed by chiropractors, when no chiropractor was even involved in the case.

"In 11 cases of the 21...that Ernst reported as [spinal manipulative therapy] administered by chiropractors, it is unlikely that the person was a qualified chiropractor," the review found.

What is interesting here is that Edzard Ernst is no rookie in academic publishing. In fact, he is a retired professor and founder of two medical journals. What are the odds that a man with this level of experience could overlook so many errors in his own data?

The likelihood of Ernst accidentally allowing so many errors into his article is extremely small. It is far more likely that Ernst selected, prepared, and presented the data to make it fit a predetermined conclusion.

So, Ernst's article is either extremely poor science, or witheringly inept fraud. I'll let the reader draw their own conclusion.

Interestingly enough, being called out on his antics has not stopped Ernst from disseminating equally ridiculous research in an unprofessional manner. Just a few days ago, Ernst frantically called attention to another alleged chiropractic mishap, this one resulting in a massive brain injury.

Not only has he not learned his lesson yet, Ernst tried the same old sleight of hand again. The brain injury, as it turns out, didn't happen until a week after the "chiropractic" adjustment, making it highly unlikely, if not impossible, for the adjustment to have caused the injury in the first place. Secondly, the adjustment wasn't even performed by a chiropractor. As the original paper points out, "cervical manipulation is still widely practiced in massage parlors and barbers in the Middle East."  The original article makes no claim that the neck adjustment (which couldn't have caused the problem in the first place) was actually performed by a chiropractor.

It is truly a shame that fiction published by people like Ernst has had the effect of preventing many people from getting the care they need. I can only hope that someday the biomedical research community can shed its childish biases so that we all might be better served by their findings.

The future's so bright, I gotta wear shades.

I feel a bit like Janus today. He was the Roman god of transitions; usually depicted with two faces, one looking forward and one looking back, Janus stands at the crossroads of our lives, guiding our passages from where we are to where we shall be. Today, I look back on what, in 2015, becomes two decades of private practice, and where I will be going in the future. So for a moment or two, Janus I shall be. 2014 was a year full of new beginnings for me, both personally and professionally. I’ve made a great many new friends, and enjoyed a renewal of both intellect and spirit. It was also the year I rediscovered my voice, as my writing -- once my career -- has again begun to flourish, not only publishing on my blog, but also at other sites such as the Good Men Project. My book has been resurrected, and is finally making steady progress.

The Center for Alternative Medicine, my practice in Litchfield, also saw an incredible amount of expansion in 2014. I introduced my private line of supplements for general health, assisting people with chronic diseases, and to support mental health issues such as anxiety and depression. This, along with my ability to create custom herbal formulas for patients, has fulfilled a life-long dream of mine; the ability to incorporate my knowledge, not only into the recommendation or use of herbs and nutrition, but in their creation. This is a wonderful capability that will benefit all of my patients, regardless of whether they are seeing me for physical injuries or internal disorders.

I am the only doctor in Connecticut, to my knowledge, that has ability to offer both of these services. It has taken years of education and experience to reach this point, and my heartfelt thanks goes to all of those people who have helped me get here.

Growth occurred internally, as well. Over the course of this past year, I went from having a single employee to three employees. Though most of my patients don’t see anyone except the person at the front desk, behind the scenes I now have people handling the medical billing as well as bookkeeping and accounts receivable. This rapid growth also had me working hard on administrative issues, developing the policies and procedures that never had to exist before.

The front desk is now in the capable hands of Giselle, whose laughter is infectious and whose efficiency is becoming legendary. The steely-eyed Joanne is facing off with the insurance companies, making sure that they live up to the promises they made to you, my patients. And Thanhien, who has managed million-dollar payrolls in her sleep, is making sure that our cash flow runs evenly. I could not ask for more capable hands to assist me.

As if those weren’t changes enough, I have an ambitious program outlined for the next year, with some entirely new services.

In December, I passed the examination to become a federally certified Medical Examiner, and am now one of only a handful of doctors in Connecticut who offer the medical examinations required every two years for everyone who carries a commercial drivers license. I really enjoy doing these exams, as I get to explore with drivers the wide range of health issues that effect them. I have already uncovered a few serious illnesses during the course of my exam, and helped drivers find appropriate care for them.

I also now have a CLIA-certified laboratory on site, and in partnership with a couple of other laboratories, we can now provide a comprehensive suite of employment and forensic testing services.

I now have the ability to provide breath, urine and hair analysis for drugs of abuse, for everything from alcohol to opiates. When these test results are required for evidence in court, I have the ability to provide what is called “chain of custody” handling, which means that the sample is overseen from collection to analysis, virtually eliminating the possibility of intentional or accidental tampering.

I can also provide a full range of relational DNA testing, including gestational paternal testing. This means that, with a couple of blood samples, I can determine the father of a child even before it has been born, with 99% accuracy. I can also perform non-invasive parental DNA tests, as well as testing for multiple siblings.

My DNA testing, like the drug testing, can be done with chain-of-custody handling for the court or other agencies, or even to support immigration and citizenship claims.

The best thing is that I am making all of these services as affordable as possible for the average person.

Anyone who has picked up a paper in the past few years knows that medical services and products are incredibly expensive and have a huge markup. This is, in part, due to the inefficiencies of the medical system, with huge amounts of overhead.

I, on the other hand, have been a sole practitioner for decades. I know how to keep my overhead low, and as a result, I can offer these services more conveniently and at less cost than anyone else.

Ok, so is that the crop? Let me think...private line nutrition, custom herbs, new staff, DOT exams, drug testing, DNA...yep, I think I covered all the bases.

Oh, yes, except for one thing:

I want to thank every single one of you who helped make 2014 the incredible year it was. My patients, my friends new and old, and my family have given me so much for which I am grateful. I can only hope that I have given back in equal measure. I wish for all of you the most wonderful year to come.

From pain and cane to freedom.

I am thrilled. Early last winter, a patient walked into my office -- barely. She had suffered from intractable back and leg pain for a year, and was, literally, days away from surgery. Her spinal stenosis was killing her. She shuffled with her back permanently bent 35 degrees from vertical. Straightening up was impossible as it would send jolts of pain down her legs. With her head forced downward, she couldn't see very far in front of her. All she could see was the ground and pain.

We had some great initial success. After her first visit, she cancelled her surgery. After a couple of months, she got rid of the walker. A little bit longer, and she didn't need a cane. Then she started standing upright, taking walks, and talking about getting off all of the pain medications she had been on.

Throughout her recovery and rehabilitation, she would comment on my trike, which I frequently ride to work in lieu of driving or walking. As it turned out, she had once been an avid cyclist, but her back problems had taken that away from her years ago. As she improved, I suggested the trike as a great way of regaining strength in her muscles without risking falling. She loved the idea, but never quite felt ready for it.

"Maybe one of these days," she would say. I could see in her eyes that she wasn't sure that day would ever come.

With a home rehabilitation plan in place and less need for my oversight and treatment, I discharged her from active care early this summer. Today, she came back to see me for a long-term follow-up.

She was doing well, she said. No pain medications for months, she wasn't in pain, and she couldn't believe the amount of energy that had returned since the heavy-duty painkillers had been eliminated from her system. I could see her eyes were bright, she had a liveliness to her step that hadn't been there before, and the color had returned to her face.

As I concluded the visit, she said there was one other thing I needed to know.

"I bought a trike," she said, grinning ear to ear. "It's pink."

I left the exam room with a huge smile of my own. It's patients like her who make this profession rewarding beyond words.

Fathers, Sons, Daughters, Paths and Patients

Nearly 17 years ago, my youngest daughter took her first steps at the airport on the way to attend my father's funeral. That moment, in the sterile hallway of an airway terminal, I experienced a strange crossing of emotions, as grief over the loss of the man who held my hand as I muddled my way through childhood collided into joy and pride as my daughter began her own long walk to independence. I didn't know what to do, really, so I did what my father had always done for me. I smiled at her and told her how very, very proud I was of her.

That's a memory I don't go to often, or willingly, but today it came unbidden and I suddenly realized how  much of my life has revolved around walking, and the paths on which we walk. I was no more than 14 or 15 when, enlisted by my mother and my best friend, I helped to create a woodland trail. Back in the late 1960s and early '70s, when land was less precious and government less war-crazed and more civic-minded, the Corps of Engineers bought up a huge tract of land -- an entire watershed, as a matter of fact -- so that they could build a dam and flood thousands of acres of what had been perfectly arable land. The ostensible reason was as a flood control measure for the downstream Ohio River, but everyone knew that the real reason was to create an outdoor recreation area in what had been a relatively backwater part of the state. I'm pretty sure the governor's  brother-in-law had a lot of real estate in the region, real estate whose value would  see a sharp increase as soon as the dam was completed and the farmland flooded.

But that wouldn't happen for a few years, yet. So in the meantime, I, and my friend Brian, and my mother, and his family, all chopped and cut and sweated and trampled and created many miles of trail to be used by both hikers and equestrians.

My first backpacking trip occurred on that trail, also with my friend. Out of plans found in a Boy Scout Fieldbook, I had built myself a wooden frame, wrapped it in canvas, and hooked onto it a packbag purchased at a local Army-Navy surplus store. Brian and I walked, and talked, and tried to make a no-match fire and cooked some undescribable and barely edible mess of freeze-dried food. It didn't rain, which was good, because our tents, such as they were, were simple tubes of plastic held up by a length of parachute cord. But I so clearly remember walking along the side of the soon-to-be-dammed creek, and seeing the muskrat holes in the banks of the stream, and poplar trees holding themselves violently upright with roots gripped tightly around the sedimentary rocks exposed by the meandering stream.

We knew nothing about trailbuilding, of course, simply cutting through what seemed to be the most reasonable and scenic route along the creek and the alongside the woodlands that lined it. We all knew that it wouldn't last long. The Corps of Engineers' creep to completion was as sure as it was slow. That path -- my first path -- is long gone, a sunken treasure of my adolescence.

I thought nothing of it at the time, for in that headlong rush with which the young meet the future, I had already found another berth. The day after graduating high school, I left my home in Ohio for New Hampshire, where I had secured a coveted spot on the professional Trail Crew of the Appalachian Mountain Club. At that time, it was the only professional trail crew in the country, and had a hallowed 75-year history in the most blue-blood of conservation organizations east of the Mississippi.

As a graduation gift, my parents had bought me a private berth on the Lakeshore Limited, an Amtrak route from Cleveland to Boston. From there I would find my own way to Pinkham Notch, New Hampshire, the place to which my compass would always point for the next several years. My father gave me a kiss, and a hug, and told me that no matter what I did, as long as I did the best I could, he would always be proud of me. As my train pulled out of the station, I waved to my parents. My dad had tears running  past the big smile on his face.

In the White Mountains of New Hampshire, I learned the craft of the trailbuilder. I learned how to drop a pine tree with a double-bit axe and skin the bark off it, sticky sap dripping from the naked wood, making it slippery to carry to its fate as a step or a footbridge or a waterbar. I learned how to quarry rock as large as bales of hay and roll its ungrateful mass to the trail, where I would dig a hole and expertly drop it in, leaving a flat, immutable surface to set foot on and another step in a long staircase up the side of one or another mountain. I remember one week counting in amazement after two of us, working together, had created 122 steps on a trail leading to Mizpah hut. Unlike the creek trail of my youth, these trails were made to last. Our goal was to create masterpieces that would last 100 years.

But building the Appalachian Trail was only part of my education. I also learned how to cook for six hungry men, how to motivate a ragged crew through their fifth straight  day of rain and mud with a little snow mixed in for variation. I learned what it meant to be part of a tribe. I learned to love and be loved. I learned how to absorb the beauty and majestic power of the mountains and make it my own. The trail I was building was to my own manhood.

I emerged four years later, stronger, hardier, and with an  unassailable sense of self. I knew who I was, and I knew the depths of my endurance.

Years passed, as they do, but the path never let me go. As I retooled from my first career to become a doctor, I also became a father. Thursdays, the traditional off day for chiropractors, became Daddy Day, and I soon found myself walking the wooded path holding the hand of Daughter #1, who contentedly ambled with me, stopping frequently to crouch down and intently examine a leaf. Or a bug. Or a pebble. Every week, we would walk along the same path, each trip filled with new discoveries.

One time we were walking along and she pointed to a log. "What's that, Daddy?" she said.

"That's a log, sweetie," I said.

"Where do logs come from?" she asked.

"A log is a tree that died and fell down," I told her.

Her eyes got wide. "It died? Why did it die?"

"Well, they have to make room for the other trees. See, when an old tree dies, it falls down to make room for a new, young tree to take it's place."

She chewed on that for a while. Then she took my hand and we began walking again. But she asked about it a few more times before she could really put her mind at ease about the whole subject.

Daughter #2 was the force behind my return to the mountains of my past. At the ripe age of 9, she decided she wanted to climb Mt. Washington with me. Of course, she thought the summit of Mt. Washington was a half-hour hike like the one to the summit of Mt. Tom here in Litchfield. She was a bit surprised on that June day when I pointed to that snow-capped summit half covered in clouds and told her that was where we were going.

No matter how you cut it, the trip up Washington is arduous. We went via Tuckerman Ravine, where we encountered our first snow, and then as soon as we hit the ridge, we entered the land of ice and clouds and wind. For hours we climbed, carefully moving from cairn to cairn so we wouldn't lose our way, as the path at that altitude was nothing but jumbled boulders and rock. By the time we reached the summit, visibility was down to about 30 feet, the wind was whipping us at 60 mph, and I don't even want to think about how cold it was. This was no simple hike for a nine-year-old. Daughter #2 was pushed hard by the trail, but she pushed right back.

After a short lunch break, we began picking our way down to Boot Spur. And as we reached the edge of the spur, a sudden gust of wind shredded the last of the clouds that had held us in blindness for so long.

"Look, honey, look!" I said, and pointed off the edge of the ravine. From 30 feet our visibility had gone to 30 miles, and you could see the whole majestic spread of the Presidential range and the valley from which we had climbed. My daughter's eyes grew as big as saucers. And I knew she would never look at the world the same again.

Today, I saw a new patient, someone who had been having back pain for several years, and the first thing I did, as I usually do with patients suffering from chronic back pain, was watch her walk. A biomechanically correct stride is important, and that's what I was analyzing, but as I did that, another part of my brain was thinking that how we walk says so much about who we are. And suddenly, I was taken back in time, to my daughter's first steps and my father's last. The friends who walked with me along parts of my path, and the miles I have walked alone. The bear I met in Maine, and the girl I met in Boston, who walks beside me still. And how even after all of these years, I can still skip surefootedly from root to rock and across the stream.

The skills of a trailbuilder are many. These days I no longer build anyone else's path but my own. But I'm putting the skills I learned walking the many paths of my life to good use, helping others walk along the paths they have created for themselves. There is little that could be more gratifying.

Of Reps, Wraps and Payola

I've never been one to hide my disdain for the tendency of mainstream medicine to allow financial incentives to color medical research and decision-making. In fact, what the record industry once called "payola" -- and which rocked that industry to its core in the 1950s -- is accepted practice in the medical industry.

As former Editor-in-Chief of the New England Journal of Medicine Marcia Angell has pointed out in her books and elsewhere, medical research has been virtually overrun by checkbook research -- with Big Pharma paying the Big Money to get the results they need.

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine,” Angell said.

She's not the only one to have seen first-hand the corruption of medical research. Take, for example, this quote from an abstract of a paper on vaccinations. This article was published by a group called the Cochrane Collaboration, an international collection of scientists who have volunteered to review medical research in the effort to develop evidence-based practice guidelines. And this is what the scientists had to say about the research on the influenza vaccine:

"Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration. Our results may be an optimistic estimate because company-sponsored influenza vaccines trials tend to produce results favorable to their products."

But the real problem of Pharmaceutical Payola occurs much further down the food chain, at the offices of individual doctors. Multiple studies have found that pharmaceutical marketing has dramatic impact on doctor's prescribing habits.  One of the most effective ways of influencing doctors is through providing continuing medical education credits for free through company-sponsored seminars.

I've seen this influence more directly through the eyes of others. I once knew a woman who worked for a specialist group practice; her sole job was to review drug company studies, and advise the practice as to which ones in which they should participate. Her decision algorithm, however, had nothing to do with scientific advancement or patient wellbeing. Rather, her recommendations were entirely based on which studies would prove most lucrative to the practice. Because what the doctor doesn't tell you, dear patient, when he offers you a chance to be cured by this new breakthrough drug that they are testing, is that he is getting paid anywhere from $6,000 to $18,000 for each patient he enrolls -- plus another $20,000 when he hits the 20-patient mark.

Not surprisingly, all of this kind of bothers me. It bothers me mostly because detractors of alternative medicine routinely claim that mainstream medicine is "based on science" and alternative medicine is not. Nothing could be further from the truth.

In fact, the opposite is likely to be more consistent with reality. According to one study, fewer than 20% of mainstream medical procedures are supported by research. Only one-half of medical interventions are therapeutic. And very, very few surgical procedures are subjected to double-blind trials before widespread acceptance.

In contrast, chiropractic care for a variety of musculoskeletal ailments is well documented in the scientific literature. Acupuncture has an exceedingly long trail of research, and nutritional interventions are "alternative" only in the minds of troglodytes.

Whether I am adjusting someone for their headache, using acupuncture to treat a child with Tourette's, or using diet and nutritional supplementation to help a patient eliminate their arthritis pain or control their autoimmune disease, I can in every case point to research supporting my use of those procedures. And, unlike in mainstream medicine, nobody -- but nobody -- makes money from research into nutritional therapy or chiropractic. So it is unlikely to be tainted by money, even if the players in the industry had the finances to do so.

Which, at long last, brings me to the point of this post. (In journalism, this is called "hiding the lead." When I was a newspaper editor, I regularly chastised my reporters for doing this.)

Coupled with my scorn for mainstream medicine for allowing itself to be bought by the highest bidder has always been my admittedly sanctimonious opinion of my own ability to stand above the fray. I have even bragged that the largest gift I have received from any nutritional company was a case of apples (It was from Douglas Laboratories, back in the 90s) and a bottle of honey.

All of that changed yesterday, however, when a rep from one of the nutritional vendors whom I use for patient's supplements stopped by. My relationship with this company is less than a year old, but not for lack of interest. I first encountered them several years ago at a nutritional conference I was attending. Impressed by their products at the time, I have intermittently contacted them for more information, but never received any response. I'm not surprised; in the larger scheme of things, my little practice in Podunk, Connecticut is not going to bring out the big marketing guns.

Purely by serendipity, however, that changed last year. One of their reps stopped by, unannounced, saying that she had seen my sign in passing, and wanted to introduce herself. I'm pretty sure that she was on the way for Someone Else's Office and just got lost, but it was a serendipitous visit nonetheless. In a short introductory meeting, I let it drop, without qualification, that what would sell me was science. And quality. And if their products did not stand up to either, #thankyouverymuchbutbutnothanks.

A few weeks later, she showed up again, armed and ready. She dropped journal after journal in my hands, explaining how it fit into her company's products and the benefits provided. I was impressed. She left, and I did some homework; she wasn't just blowing me smoke.

So I ordered a few products, and began using them. Patient feedback was good, but more importantly, patient improvement, documented objectively, was impressive. I know, there's always the problem of confirmation bias when a clinician reviews his own work, so I can't conclude from a truly objective standpoint that the products worked. But you have to go with what you've got, sometimes.

This company offers a number of conferences, and at her last visit, I asked the rep why they don't include CEU credits for doctors attending them. Her answer was simple, blunt, and honest.

"We won't," she said. "We talk about our products."

Compare that answer to that of the pharmaceutical companies, which routinely spend millions of dollars sponsoring CEUs for medical doctors, and consider it a routine cost of doing business. I have attended some of those lectures, all of which have been extended infomercials for one or another miracle drug. The fact that this nutritional supplement company specifically delineated a difference between education and marketing was impressive.

At this visit, she also plopped another inch of independent research on my desk, and we talked about the scientific backing for some of their new products.  I was so engrossed by the information, that I completely forgot about the wrap she had brought from some deli.

I shouldn't have; this was unique. During her previous visits, she had never provided me with a free sample of anything, except as a quick taste test when I had mentioned that other, similar products had been met with unhappy looks from my patients.

So engrossed was I with the data that I forgot about the sandwich. Sandwiches, by the way, fall well within the guidelines for proper behavior for representatives visiting doctors, so I did not feel any gross or subtle moral violation for accepting the food.

After the rep left, I got around to opening it up, and discovered, perhaps, the Best Wrap I Have Ever Had In My Entire Life. I immediately emailed the rep to get her source; she demurred, however. So I still don't know where The Wrap came from.

So I have to confess. In addition to having been courted by a case of Red Delicious apples, I have now been waylaid by a chicken wrap of unknown provenance but undisputed tasteworthiness. That is the full extent that any company has sought to influence my prescribing behavior.

So the next time I recommend a supplement to you, I want you to have full and transparent knowledge. I'm doing it for the wrap.

The Power of Chiropractic

Thursday's wild storm left the Center for Alternative Medicine without power for a day, and what an unusual day it proved to be! Though my hours were quite fully filled for Friday, I went in that morning with low expectations for the day. I told my ever-suffering office manager, Teresa, to stay home, as I expected that I would easily be able to handle what few patients showed up.

Of course, I had no idea of exactly who that might be, as I converted to entirely digital scheduling and medical records several years ago. In fact, when it comes to solo doctors' offices, my practice is pretty close to the bleeding edge, technologically speaking. I have set up a highly integrated network of Linux-based servers, desktop systems, laptops and netbooks and even smartphones, all entirely fueled by international-standard FOSS software. In fact, to my knowledge, I am the only doctor in the country whose practice is entirely built around the Ubuntu operating system. We use no Windows or Mac operating systems or applications, from patient charts to accounting.

All of which, of course, was of absolutely no use on Friday. Even a battery-powered laptop was ineffectual, as it needed a functioning router and powered-up server to tell me anything about anything.

So I went into the office Friday morning prepared to amuse myself by engaging in an archeological dig through the junk mail, research journals and meaty tomes on acupuncture which have been serving to hold my desk firmly onto the floor for a few months.

I abandoned that project, mid-pile, when my 9 o'clock patient walked through the door. Then the 9:15 patient showed up. And all of a sudden, in darkened office with windows opened to the breeze, my day came alive. The next time I looked at the clock, it was lunchtime. I took a quick lunch, and was back at it for another 6 hours.

It was at some point, while I was blending a custom herbal formula for a new patient by the light of the sun streaming in the laboratory window, that I realized just how independent of technology is the practice of primary care chiropractic. Here I was, with no notes, no power and no machines, treating patients as I would on any other day.

Granted, it wasn't quite the same. With no water for washing my hands between patients, I resorted to rubbing my hands with alcohol, not a dermatologically comfortable practice when you are doing it 30 or so times. And without power, the bath of hot water in which I store my thermal packs is just a bath of tepid water.

As many of my patients know, I often apply heat prior to myofascial therapy because it makes the process a bit less painful. So a few of my patients on Friday experienced a tad more discomfort than usual, but all managed to take it in stride.

Chiropractic adjustments were similarly easy. I've chiropractically examined and adjusted people just about everywhere and on just about everything, from logs deep in a national forest to incubators in a neonatal ICU, so adjusting in natural light with the windows open did not even draw conscious notice on my part.

Acupuncture treatment was a bit trickier. The room in which I usually treat my acupuncture patients is without windows, and is dark as a cave with the lights off. So I re-fitted one of the tables in my other exam room with outriggers to be used as a suitable acupuncture room.

What was more difficult was determining treatment protocols and plans, all of which comprise part of a patients' chart. For each patient, I note where I am adjusting, and which adjusting techniques are used. And I will often alternate complementary therapies. Acupuncture patients also have an individualized point prescription which I follow for treatment. With none of these available, I was forced to rely on my memory.

Interestingly, I was pretty successful. Fortunately, a chiropractic doctor develops a close enough relationship with his patients that when my memory did falter, people cheerfully volunteered the information, often with a teasing jab at my stumble. It was all good-humored though, and nobody seemed disaffected because they had to remind me of my duties.

And when their treatment was finished, it was "Goodbye, I'll have Teresa call you about appointments and payments!" Nobody seemed to mind. Everybody likes to leave the doctor's office without having to pull out their wallet!

Notes were jotted down on pieces of paper and put on the desk for transcription when the power went back on. At 4:30, I walked out of a treatment room, and realized that there were some lights on in the hall. The CL&P linemen had pulled out all the stops in getting the power back up; and I recalled that some time earlier, I had seen a truck hauling a rather oversized transformer up the road. Perhaps a swap had been made.

But by then I had established a rhythm to the day, and I decided not to disturb it. Until hours ended at 6:30, I continued to work the day old-school style, sleeves rolled up, as chiropractic doctors have for generations before me. It was really a very welcome return to my roots.

For a few minutes before I left on Friday, I sat on the bench in the front of the Center and reflected on the day. Though busy, it had proved to be exceedingly pleasant. Without telephones or email to pester me, I was really drawn into the present and the presence of my patients to the exclusion of all else. As I have written before, it is really that relationship, between patient and doctor, that is the source of my joy in my work; to have it enhanced in that way was not only surprising, but also served as a reminder to me. It was a call for me to, professionally speaking, stop and smell the roses. To forget the distractions and to focus on what is truly important:

The healing power of both touch and words. The ability of laughter to pierce through pain. The sincere "thank you," unblemished by commerce. Those are the things that matter to both my patients and myself, and in turn make my practice as healthy and robust as it is.

Isn't it funny how a loss of power should actually become its reclamation?

Dr. Avery Jenkins is a chiropractic physician specializing in the treatment of people with chronic disorders. He can be reached at alj@docaltmed.com or by calling 860-567-5727.

Guilty By Association

The history of chiropractic has, to a great degree, been formed by its response to its enemies. Of all of the forms of alternative health care which arose in response to the callous use of "heroic medicine" by the medical profession of the 19th century, chiropractic was the only one to survive intact. And not only did chiropractic survive, it thrived. While the homeopaths were chased out of the U.S. to find tenuous purchase in Europe, the osteopaths were co-opted to become the red-headed stepchildren of medicine, and the Thompsonians and Eclectics were simply annihilated, chiropractic doctors spread to every state in the Union and got licensing laws passed in all 50 states.

To a large degree, the success of chiropractic legally was due to its success with patients. The legalization of chiropractic was enabled by grass-roots patient movements lobbying their state legislators to turn aside medicine's attempt to quash the young profession. When chiropractors were jailed for "practicing medicine," their patients would line up at the door of the jail, requesting admittance so that their chiropractic doctor could adjust them.

Chiropractic progress was also secured by enormously courageous doctors willing to risk jail terms in order to gain the right to serve their patients. I never knew it at the time -- indeed, I did not discover this fact until I was well into my 30s -- but the chiropractic doctor I saw as a child, Dr. Herbert Reaver, was jailed no fewer than 13 times before the state of Ohio finally passed a chiropractic practice act. Dr. Reaver, one of the unsung heros of health care, continued to see patients into his early 80s.

While chiropractic success was largely built on patient demand and individual acts of courage, such as Dr. Reaver's, the medical model pursued a different tack. It employed an enormously well-funded central association -- the AMA -- to attempt to eliminate medicine's economic competition.

And that, really is what today's question is about. Can you tell me what the AMA, the Joint Commission on Accreditation of Hospitals (JCAH) and the American College of Physicians all have in common with regard to the history of chiropractic?

As always, the first person to send me the correct answer will receive a 10% one-time discount on any order of supplements from our dispensary.

Good luck!

Dr. Avery Jenkins is a chiropractic physician specializing in the treatment of people with chronic disorders. He can be reached at alj@docaltmed.com or by calling 860-567-5727.

The Map of Human Health

On the surface, it was just another typical moment in a chiropractic physician's office. I was walking down the hall from one treatment room where I had just left a patient with an injured knee, to check on another patient who was receiving care for a painful shoulder. But on that short walk down the hall, I was actually walking the long divide between two health care paradigms. While the patient with shoulder problems was receiving what would normally be considered "standard" treatment -- heat, ultrasound and chiropractic manipulation -- the patient with the bum knee had several acupuncture needles inserted around her knee and ankle.

In one room, the basics of applied physiology were being utilized: Heat was being used to perfuse the injured area with blood, bringing with it oxygen, nutrients, and other supplies for healing, and taking away the detritus of repair. Ultrasound was altering the permeability of the cell membranes, allowing the injured tissues to more readily imbibe the blood's bounty. And joint manipulation was restoring normal physiological shape and function to the ligaments surrounding the joint.

But in the other room, a completely different process was apparently taking place: The normal flow of qi, a nebulous "life energy," was being restored. Excess yang, represented by the heat of inflammation, was being quenched by employing the water principle of the body, as water is always used to put out a fire; meanwhile, meridians controlling the patient's earth energy were used to nurture the damaged tissues.

How do I, as a doctor trained in both eastern and western medicine, reconcile these two utterly divergent approaches? One is so clearly logical and wrapped in the science of the west, while the other explodes with image and allegory, as if the needles tell a parable of health in their placement and actions.

And with increasing frequency, I find that I not only combine these disparate therapies in my practice, but in the treatment of singular patients. Some patients receive both chiropractic and acupuncture. Some are treated with eastern herbs and western physiotherapy. Others are treated with western nutrition and acupuncture.

"Do I contradict myself? Very well then I contradict myself," said the poet Walt Whitman. "I am large, and contain multitudes."

Perhaps the best way of uniting these two approaches to human health which do not speak the same language either literally or figuratively is to apply the principles of scientist and philosopher Alfred Korzybski which can be best summed up by this statement:

The map is not the territory.

Too often, Korzybski argued, we look at a thing and we conceptually "map" it. We assess its shape and weight, its color and texture, and assign those properties to that object, forgetting that it may have other properties of which we are not aware -- or that it may not always have those properties which we have assigned to it.

That's a mouthful, I know. An easier way to understand the concept is to imagine two maps of the same place, for example Ansonia, Connecticut.

One map is a road map.  It clearly shows all the roads in the area, what their names are, and where they go.

The second map is a topographic map. This map does not show the roads so clearly, but it does give us other information that the road map does not. Through the use of contour lines, it shows us the hills and valleys of the terrain, where the swamps are, the steepness of the slopes.

Both maps show us the exact same territory. But they provide us with entirely different types of information.

In the pursuit of understanding, we all too often forget that the theories and hypotheses that we make -- the maps, as it were - are only maps. They are not the territory itself. The map of the human body developed by western medicine is certainly not the only map, nor is it the "true" map. It is merely a map that shows us certain characteristics of that territory. Imagine the arteries and veins as roads, the organs as cities and villages, the nerves as railroad tracks...you get the picture.

The map developed by Traditional Chinese Medicine shows us different features of the human body. Instead of roads and tracks, we see the swamps and the forests, the peaks and the valleys. Entirely different information, but also of great value as I help my patients navigate their way back to health.

Is one more valid than the other? I think it would be the height of arrogance to claim that the western medical map was superior to the eastern. After all, 100 years ago, the eastern map of human functioning was already highly detailed and had been refined for centuries, while western medicine was still scrawling  "here be dragons" on the margins of its crudely-drawn understanding.

I employ both, because I find both to be useful. They help me and my patients reach their destination. And as I continue to proceed along the twin paths of east and west, I find that I can increasingly see one in the other. From the road I see the hills, and from my path in the hills I can hear the hissing of cars on the road. I think -- I hope -- that my patients will be the beneficiaries of this understanding.  As the wise Siddhartha said, "In the sky, there is no distinction of east and west; people create distinctions out of their own minds and then believe them to be true."

The Power of Touch

While on vacation last week, I had the opportunity (and the need) to do something I rarely do at home: Get a chiropractic adjustment. The need was spurred by a headache subsequent to a 100-mile bike ride that saw me traverse Cape Cod from outermost Provincetown to downtown Hyannis, and back again. It was a pleasant trip, though exceedingly hot. And even though I ride a recumbent bicycle, which is far more comfortable for the neck over long distances than a standard upright, the recumbent in the extremely laid-back configuration can produce significant neck strain over time.

I was greeted on the morning following my ride, by a classic cervicogenic headache -- that is, a headache caused by the vertebrea in the neck becoming fixed in position. This is the cause of most headaches, which in the popular literature are often referred to as "tension headaches."

I had been needing an adjustment for some time, but like the average bad patient, I kept putting it off. In part, because most other chiropractic physicians work the same hours as myself, and in part because I've just been too busy. Sound familiar?

I was fortunate, however, to find that Dr. Donna Heitzman, in Provincetown, would have a few minutes to see me that afternoon. As Dr. Heitzman, a delightful woman with a puckish sense of humor, treated me, I was reminded of just how powerful the act of simply touching someone can be.

Arguments for the healing power of touch sends skeptics into paroxysms of denial, as healing touch is often so closely associated with fundamentalist religious practices, and the denial of the spiritual aspect of humanity is a fundamental tenet to the skeptic's belief system.

Nonetheless, there is a significant body of research which demonstrates the power of touch. Most recently, researchers found that the quality of objects that people were touching -- heavy vs. light, hard vs. soft, rough vs. smooth -- caused people to form unconscious associations between what they were touching and unrelated experiences. For example, rough objects made social interactions more difficult and hard objects made people more rigid in negotiations.

Massage has been shown to prime the brain for release of oxytocin, commonly known as the "empathy" hormone, making people more capable of bonding with and trusting others.

But touching is even more powerful than that. Touch has been shown to reduce cardiac arrythmias in ER patients, and even have beneficial effects on the red blood cells of comatose patients. Touch also increases one's overall sense of well-being and reduces blood pressure.

Of course, chiropractic adjustments are all about touch, and I am very conscious of the quality of my touch when I am treating patients. Not infrequently, patients will experience an overwhelming emotional response to a chiropractic adjustment. Crying, laughing and sudden relaxation are all common responses to a chiropractic adjustment. Part of it is due to the neurological and biochemical changes which adjustments create, and part of it is simply due to being touched.

Which brings us back to Dr. Heitzman's office. Immediately after being adjusted, my headache disappeared, which is a common response to chiropractic treatment of tension headaches. But more surprising to me was the overwhelming sense of relief I felt. In addition to the emotional relaxation, I felt the muscles of my upper back and shoulders let go of tension that I didn't know they held.

Dr. Heitzman and I spent a few more pleasant minutes talking shop, and then I proceeded to hop on my bike and ride an easy 7 miles back to the house where I was vacationing. A long nap that afternoon ensued, unusual for me.

It was good to be reminded in such a direct, clear way of the powerful treatment that I can offer to my patients. When the "Gee, thanks Doc, that feels a lot better" response becomes commonplace, it is all too easy to forget the powerful sensations lying behind those words, the power of a chiropractic adjustment and the power of a healing, caring touch.

The Business End of Being a Doctor: Telephone Technology

As I do periodically, I reviewed the costs of the practice this spring, and was, frankly, appalled at how much I was spending for a second phone line -- a line which was used primarily for faxes, incoming call rollover, and for me to return patient calls or to call the kids and remind them to clean their rooms. I felt there was probably a better way to spend this money, particularly as there are easier and cheaper ways to provide the same services.

So, step 1 was to move to an internet fax service. For pennies per month, this service provides a dedicated fax number. Incoming faxes such as lab reports are mailed to us as a PDF file, which we can then immediately transfer to the patient's electronic file. No paper, no printing, no muss, no fuss.

Outgoing faxes are simply PDF files emailed to the service which then sends them to the receiving party's fax machine. So, for example, when I make a referral to another physician or to the local lab, I no longer have to print it out and have Teresa schlep it through the fax. Instead, I make the referral through the electronic medical records system, save it as a PDF file, and email it to the service. Takes maybe 15 seconds.

With the need for a fax line obviated, we dumped it. But then another problem became apparent, because I ended up using the single line for making outgoing calls, such as returning calls from patients and the periodic calls to home that are routine in any working parent's day, to make sure the hermit crab got fed and that nobody was doing anything that would result in concussions or uncontrollable bleeding, and to say, yes, I will spend my lunchtime going to the school to drop off the homework you forgot.

Clearly I needed a second line, so I started using Skype for calls to landline and mobile phones. But I've never really been a big fan for several reasons, among them being that Skype uses proprietary protocols. Last year, I converted the entire office from Windows to the Ubuntu (Linux-based) operating system, which I found to be far more effective for our needs. With the most recent upgrade to the Ubuntu 10.04 operating system, my Skype broke completely, insofar as being able to call landlines and mobiles on it. I could  still make Skype-to-Skype calls with no problem, but forget calling the kids or returning patient calls. Skype's tech support was only mildly interested in the problem, and eventually told me to purge the software and reinstall it, and if that didn't work they were washing their hands of the problem.

Needless to say, it didn't work. So I went in search of an alternative, and found Nomado. For a paltry 5 euros per month, I got my own incoming phone number, 500 minutes/month of talk time to almost any phone in the civilized world, automatic call forwarding to my cellphone and voicemail that is emailed to me as .wav files. And all at a price that is almost 50% less than what I had to pay Skype for same.

The voice quality is perfect, better than Skype, and far better coverage for calling Europe, the UK and South American countries. Plus, it uses the SIP protocol -- an open source protocol -- which means I have my choice of PC-based softphones as well as hardware phones to pick from, and I wasn't stuck with the Skype non-functional software and hardware lineup.

I *highly* recommend this service over Skype. Better value, by far.

The Nomado website is a wee bit hinky, especially if you're using Firefox on Linux -- for the signup process, I had to boot up Chrome on a virtual XP machine to get the job done -- but they have online chat tech support that is superb.

So I now have a direct incoming line, with all of the bells and whistles, for about $6 per month.

With the grossly inappropriate reimbursements the insurance companies are dishing out these days, it pays a doctor to stay on top of the technology curve. That way you can reduce costs while maintaining high levels of service.

25 Things You Didn't Know a Chiropractor Could Do: #1

In my 15 years of practice, there is a comment that I have heard all-to-frequently from my patients. It is not meant unkindly, nor as a slight, but evidences surprise at my hitherto unbeknownst powers, as if I had just unbuttoned my shirt and unveiled a Superman logo on my chest. This remark is often uttered as I say something that I think is relatively innocuous, like, "Yeah, we should probably do an EKG, just to be sure."

The patient will look at me, with eyebrows raised, and say, "I didn't know you could do that!"

The problem, it seems, is that the majority of the public have been trained to see chiropractors as one-trick ponies. Good for spinal adjustments, but little else.

This distorted image stems largely from the disinformation campaign mounted against the chiropractic profession by the AMA. 100 years of lies takes a while to untangle, especially when the bigotry is backed by a few billion pharmaceutical dollars.

And it is complicated somewhat by state laws, which vary widely. In some states, chiropractic physicians can inject substances and perform minor surgery. In others, they are not allowed to treat anything except the spine.

Throw into the mix the fact that most insurance companies will not reimburse a chiropractic physician for many of these procedures, and you get a large number of chiropractic doctors who will simply will not do them, simply to survive financially. It is difficult to justify spending several thousand dollars on an EKG machine if you'll never get reimbursed for its use.

But the fact of the matter is, chiropractors are trained in how to perform and read EKGs, as well as a number of other things which might surprise you as much as it has my patients.

Which is all a very long-winded way of introducing a new feature here at DocAltMed.

Every other Friday for the next year, I will post yet another example of the many ways your chiropractic doctor can serve you that you may not have heard of. And this week, we'll start with the basics, beginning with:

Your Annual Physical Exam

This, to me, is the real shocker. That people would not realize that they can use their chiropractic physician to do get their physical exam. My physical examination is every bit as complete as that you would receive in a medical doctor's office. Actually, I would argue that it is more complete, because my exams are not only looking for signs of pathology or disease; I am also illuminating areas of nutritional or physiological imbalance. It is those latter factors which are the true harbingers of health problems.

Yes, I listen to the heart and lungs, look into your eyes and ears, and peer intently at your mouth. As you might have guessed by now, we do an EKG, and I order the same blood tests that any other doctor would order.

But when I or another chiropractic physician performs your physical exam, you get two distinct advantages. The first I've already mentioned -- we are trained, as MDs are not, to spot dysfunctions before they become pathologies. The second is that when we do find a problem, you are far less likely to end up on a prescription drug.

In fact, studies have shown that patients who use their chiropractic doctor as their primary care physician end up in better health over the long term. They have fewer hospital days, they need fewer drugs to be healthy, and for older people they maintain physically active later in life.

So when it is time for your next annual physical, think hard about what you want -- better health, more active life -- and who is more likely to be able to give that to you.

A Big Win for Chiropractic Patients

No matter where you stand on health care reform, the new law is a big win for chiropractic patients. Although the coverage of health care reform reported nary a whisper about chiropractic physicians, the legislation is set to affect chiropractic physicians and their patients in some very profound and positive ways. First and foremost, the law contains anti-discrimination provisions, which will require insurance companies to cover the full scope of chiropractic services. While you, as a patient, may not see, it, insurance companies have set up a number of roadblocks in front of your care. The first one is that most insurance companies will only pay for one, or maybe two, of the many therapies that a chiropractic physician can perform. So if you need more care than a hot pack and a spinal adjustment, you're out of luck. Either your chiropractic doctor provides the service for free (which is what most of us end up doing) or you get charged an additional fee for your chiropractic insurance "benefit."

The second roadblock is that insurance companies have artificially restricted the diagnoses for which chiropractic care is covered. Usually anything outside of purely musculoskeletal conditions is also outside of your insurance "benefit." Do you suffer diabetes, or heart disease, and are seeking alternative care? Sorry, not covered. Are you looking for fertility treatment that has proven more effective than in-vitro fertilization, is safer, and costs far less? Oops, your insurance doesn't cover that. Would you like acupuncture -- a research proven treatment -- for those chronic sinus infections? We're sorry, but your "benefit" doesn't cover that.

In fact, I'll bet you didn't know that your chiropractic physician could treat those conditions. He can, and that's only the surface. Chiropractic doctors are skilled in treating those chronic conditions that are usually very poorly managed by drugs. But you've never been able to get that care because your insurance company refuses to cover it. In some cases, insurance companies have forbidden chiropractic doctors on their plans to even tell patients that they can provide those services.

But all of that ended with the passage of health care reform. Here's what the president of the American Chiropractic Association had to say:

“Regardless of how you feel about this legislation and its overall impact on the nation, it has to be recognized as an historic first for the chiropractic profession. We now have a federal law applicable to ERISA plans that makes it against the law for insurance companies to discriminate against doctors of chiropractic and other providers relative to their participation and coverage in health plans. Such discrimination based on a provider’s license is inappropriate and now must stop,” said ACA President, Rick McMichael, DC.

“While this does not fully level the playing field for doctors of chiropractic in our health care system, this is a highly significant step that has the potential for positive, long-range impact on the profession and the patients we serve. Congress has finally addressed the issue of provider discrimination based on one’s license, and they have said that such discrimination must stop.”

When this law finally goes into effect, that discrimination will stop, allowing you to utilize your chiropractic physician for the full scope of services for which he is qualified.

And that will be a good day for your health, and a great day for the health of this nation. Perhaps then we will begin to turn away from the pill-for-every-ill mentality that has made us one of the unhealthiest of the industrialized nations.

Happy Feet!

Yesterday's event was a tremendous success! Rebecca from Foot Levelers was booked all day long, and we were able to start bringing relief to a lot of people with foot, knee, and back problems.

Sportsmens of Litchfield also came through in a big way, providing not only discounts at the store for people who came to get their feet scanned, but also some very nice swag for everyone. Water bottles, bags and t-shirts -- many thanks to Jay and Michael at Sportsmens, for being such good sports!

Teresa did her usual fine job of managing things from the front desk, unsnarling bottlenecks and being everywhere for everyone simultaneously.

As for me, one of the things that I really enjoyed about the day was that it brought in some patients whom I haven't seen in a while. It was a real treat to catch up with people, and reminded me once again what it is that I really like about what I do.

Sure, I enjoy the detective work of being a good diagnostician, unraveling the myriad causes of a patient's health problems. And practicing the physical skills required of my profession, manipulating joints, inserting acupuncture needles, or doing hands-on soft tissue work, is a pleasure as well.

But above it all are the relationships I have with my patients: The give and take, hearing my patients' amazing stories, and telling a few of my own.

That, more than anything else, is what I look forward to when I unlock the door to the office every morning.